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the Manage22 || Guideline
DiagnosisforAnd
Management
Of Acute
ment Of Bronchiolitis
PAGE
PAGE
And
Chronic Pain
Subcommittee
on In
Diagnosis
Sickle
Cell
Disease.
And Management of BronAmerican
Pain Society.
.
chiolitis, Pediatrics
PAGE
3 | Editorial Comment
4 | The Management of Sickle
Cell Disease. National
PAGE 6 | Bronchiolitis In Children
PAGE
PAGE
PAGE
Institutes
of Health, National
Scottish Intercollegiate
Heart Lung and Blood
Guidelines Network
Institute.
8 | Editorial Comment
9 | Evidence-Based Clinical
Practice Guideline For
Medical Management Of
Bronchiolitis
Cincinnati Children's Hospital Medical Center
PAGE
10 | Editorial Comment
Current Guidelines
Guidelines For
For
Current
Diagnosis
Management Of
Sickle
CellAnd
Disease:
BronchiolitisOfInAcute
The Complications
Emergency
Management
Department
In this issue of EM Practice Guidelines Update, 2 guidelines
II
n
this issue ofthe
EM management
Practice Guidelines
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practice guidelines
that
addressing
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cell3 disease
(SCD) are
address
theAs
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bronchiolitisSCD-related
are reviewed. complications,
Bronchiolitis is a
reviewed.
a result ofofnumerous
viral-induced inflammatory disease of the lower respiratory tract in infants,
patients
with SCD have significantly diminished life expectancy.
characterized by acute inflammation, edema, and necrosis of epithelial cells
Although
patients
will mucous
be followed
by subspecialty
hemalining smallmost
airways;
increased
production;
and bronchospasm.
tologists,
SCD is fundamentally
a “‘disease
oftachypnea,
emergencies.”’
Signs and symptoms
of bronchiolitis include
rhinitis,
wheezing,
cough, crackles,
use of accessory
muscles,
and/or
flaring. The majorEmergency
clinicians
should be
familiar
with nasal
the recommendaity of cases
of bronchiolitis
are caused
bySCD
respiratory
syncytial virus
(RSV);
tions
around
management
of acute
complications,
because
other
viral
causes
include
metapneumovirus,
influenza,
parainfluenza,
and
failure to appreciate the nuances of care in these brittle patients
adenovirus. There are more than 200,000 annual emergency department
may
place them at risk for short-term morbidity and mortality. The
(ED) visits in the US for bronchiolitis among children less than 2 years of
methodology
these admission
practice guidelines
variesoccur
greatly–from
December
age, with a 19%ofhospital
rate.1 Most cases
evidencebased
to
expert
opinion–and
thus
must
applied toand
through March. There is wide variation in how bronchiolitisbe
is diagnosed
treated.
The
guidelines
reviewed
here
use
an
evidence-based
approach to
emergency practice with caution and pragmatism.
address diagnosis and acute management of this common and potentially
severe respiratory illness.
Practice Guideline Impact
Guideline Impact
•Practice
In the management
of acute SCD pain crises, bolus normal
•
•
•
•
Bronchiolitis is a clinical diagnosis; radiographic and laboratory testing
saline
not recommended
unless
the patient isbronchiolitis.
hypovolemare not is
indicated
in the assessment
of uncomplicated
ic. In euvolemic patients, intravenous hydration should not
Infants who
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age,
were
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and/or have underlying cardiac or pulmonary disease should be
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because
have
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In
the management
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specific
recrespiratory
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in
the
setting
of
bronchiolitis.
ommendations exist with regard to opiate choice and adjuvant
Whilemedications.
bronchodilators are not routinely indicated in the treatment of
bronchiolitis, a trial of nebulized albuterol and/or epinephrine may be
•
In
patientsinhaled
with SCD
and suspected
criteria
performed;
bronchodilators
shouldinfection,
be continued
only ifexist
thereto
is
identify
for outpatient treatment.
a positivecandidates
clinical response.
••
Corticosteroids
and antibiotics
arethe
not diagnosis
indicated forand
the treatment
treatment ofof
Separate
algorithms
exist for
bronchiolitis.
stroke in adults and children with SCD.
Author
April 2010
December
2009
Volume
Volume2,1,Number
Number42
Editor-In-Chief
Maia
S. Rutman, MD
Medical Director, Pediatric Emergency Services, Dartmouth-Hitchcock Medical
Center;
Assistant
Professor of
Pediatric Emergency Medicine, Dartmouth
Reuben
J. Strayer,
MD
Medical
School,
Lebanon,
Assistant
Professor
ofNH
Emergency Medicine,
Mount Sinai School of Medicine, New York, NY
Editor-In-Chief
Editorial
Board MD
Reuben
J. Strayer,
Assistant Professor of Emergency Medicine, Mount Sinai School of Medicine,
Andy Jagoda, MD, FACEP
New York, NY
Professor and Chair, Department of Emergency Medicine
Mount Sinai
School of Medicine, New York, NY
Editorial
Board
Andy
MD,
FACEP
Erik Jagoda,
Kulstad,
MD,
MS
Professor
andDirector,
Chair, Department
Emergency
Medicine
Research
AdvocateofChrist
Medical
Center
Mount
Sinai School
of Medicine, New
York, NY
Department
of Emergency
Medicine,
Oak Lawn, IL
Erik
Kulstad,
MD, MDCM,
MS
Eddy
S. Lang,
CCFP (EM), CSPQ
Research
Director,
Department
of University,
Emergency Medicine,
Advocate
Christ
Associate
Professor,
McGill
SMBD Jewish
General
Medical
Center,
Oak Lawn,
IL
Hospital,
Montreal,
Canada
Eddy
S. Lang,
MDCM,MD
CCFP (EM), CSPQ
Lewis
S. Nelson,
Senior
Researcher,
Alberta
Services;
Associate
Professor,
University
Director,
Fellowship
in Health
Medical
Toxicology,
New
York City
Poisonof
Calgary;
Professor,
McGill
University,Department
Montreal, Quebec,
Canada
ControlAdjunct
Center,
Associate
Professor,
of Emergency
Lewis
S. Nelson,
MD Center, New York, NY
Medicine,
NYU Medical
Director, Fellowship in Medical Toxicology, New York City Poison Control
Gregory M. Press, MD, RDMS
Center, Associate Professor, Department of Emergency Medicine, NYU Medical
Assistant Professor, Director of Emergency Ultrasound, Emergency
Center, New York, NY
Ultrasound Fellowship Director, Department of Emergency Medicine,
Gregory
M.ofPress,
RDMS Medical School, Houston, TX
University
Texas MD,
at Houston
Assistant Professor, Director of Emergency Ultrasound, Emergency Ultrasound
Maia Rutman, MD
Fellowship Director, Department of Emergency Medicine, University of Texas at
Medical Director, Pediatric Emergency Services, DartmouthHouston Medical School, Houston, TX
Hitchcock Medical Center; Assistant Professor of Pediatric
Maia
S. Rutman,
MD Dartmouth Medical School, Lebanon, NH
Emergency
Medicine,
Medical Director, Pediatric Emergency Services, Dartmouth-Hitchcock Medical
ScottAssistant
M. Silvers,
MD
Center;
Professor
of Pediatric Emergency Medicine, Dartmouth
Chair, School,
Department
of Emergency
Medicine
Medical
Lebanon,
NH
Mayo Clinic, Jacksonville, FL
Scott M. Silvers, MD
Scott
Weingart,
MD FACEP
Chair,
Department
of Emergency
Medicine, Mayo Clinic, Jacksonville, FL
Assistant Professor, Department of Emergency Medicine, Elmhurst
Scott
Weingart,
FACEP
Hospital
Center,MD,
Mount
Sinai School of Medicine, New York, NY
Assistant Professor, Director of the Division of Emergency Critical Care,
Department of Emergency Medicine, Mount Sinai School of Medicine,
Prior to beginning this activity, see “Physician CME Information” on
New York, NY
page 9.
Prior to beginning this activity, see “Physician CME Information” on page 12.
Editor’s Note: To read more about this publication
Editor’s Note: To read more about this publicaand the background and methodologies for practice
tion and the background and methodologies for
guideline development, http://www.ebmedicine.net/
practice guideline development, go to:
content.php?action=showPage&pid=107&cat_id=16
http://www.ebmedicine.net/introduction
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Current Guidelines For Diagnosis And Management of Bronchiolitis In The ED
Clinical Practice Guideline: Diagnosis And Management Of Bronchiolitis2
Subcommittee on Diagnosis and Management of Bronchiolitis
Pediatrics. 2006;118(4):1174-1793.
Link: http://aappolicy.aappublications.org/cgi/content/full/pediatrics;118/4/1774
T
applies to previously healthy children aged 1 month to 2 years presenting with bronchiolitis, which is defined as “a viral upper respiratory prodrome followed by increased respiratory effort and wheezing
in children less than 2 years of age. Clinical signs and symptoms of
bronchiolitis consist of rhinorrhea, cough, wheezing, tachypnea, and
increased respiratory effort manifested as grunting, nasal flaring,
and intercostal and/or subcostal retractions.” Only recommendations
pertinent to emergency medicine are abstracted here.
his document was developed by a committee on the diagnosis
and management of bronchiolitis, convened by the American
Academy of Pediatrics (AAP) with the support of the American
Academy of Family Physicians, the American Thoracic Society, the
American College of Chest Physicians, and the European Respiratory Society. The committee was chaired by a primary care pediatrician
with expertise in clinical pulmonology and included experts in fields of
general pediatrics, pulmonology, infectious disease, emergency medicine, epidemiology, and medical informatics. All panel members were
identified and potential conflicts were disclosed. The group identified
4 clinical questions and conducted a literature review according to
explicit criteria. Article inclusion criteria were specified. The process
by which evidence was evaluated for quality was not described.
The following recommendations below are abstracted from the full
guideline. To view the original guideline, go to: http://aappolicy.aappublications.org/cgi/content/full/pediatrics;118/4/1774
Effectiveness of diagnostic tools for diagnosing bronchiolitis in
infants and children
• Recommendation 1a (evidence level B): For bronchiolitis, history and physical examination should be the basis for diagnosis
and disease severity assessment. Laboratory and radiologic studies should not be ordered routinely.
• Recommendation 1b (evidence level B): When making decisions about management of children with bronchiolitis, the following risk factors for severe disease should be assessed: 1)
age less than 12 weeks; 2) a history of prematurity; 3) underlying
cardiopulmonary disease; and 4) immunodeficiency.
Recommendations were graded based on the strength of evidence
for each question:
•
•
•
•
•
Level A: Well-designed randomized, controlled trials (RCTs) or
diagnostic studies on relevant populations.
Level B: RCTs or diagnostic studies with minor limitations; overwhelmingly consistent evidence from observational studies.
Level C: Observational studies (case-control and cohort design).
Level D: Expert opinion, case reports, reasoning from first principles.
Level X: Exceptional situations in which validating studies cannot be performed and there is a clear preponderance of benefit or
harm.
Efficacy of pharmaceutical therapies for treatment of
bronchiolitis
• Recommendation 2a (evidence level B): The management of
bronchiolitis should not routinely include bronchodilators.
• Recommendation 2b (option, evidence level B): The use of
α-adrenergic or β-adrenergic medication is an option if given in
The target provider population is defined as pediatricians, family physicians, emergency medicine specialists, hospitalists, nurse practitioners, and physician assistants who care for children. The guideline
EM Practice Guidelines Update © 2010
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•
•
•
Current Guidelines For Diagnosis And Management of Bronchiolitis In The ED
a carefully monitored trial. The use of inhaled bronchodilators
should be continued only if objective means of evaluation document a positive clinical response to the trial.
Recommendation 3 (evidence level B): The management of
bronchiolitis should not routinely include the use of corticosteroid
medications.
Recommendation 4 (evidence level B): Children with bronchiolitis should not be treated routinely with ribavirin.
Recommendation 5 (evidence level B): Only children with specific indications of bacterial infection should be given antibacterial
medications. Treatment of the bacterial infection should be the
same as it would be in the absence of bronchiolitis.
Editorial Comment
Few presentations are as anxiety-provoking to the ED clinician as the
infant with respiratory distress. In this practice guideline, the AAP describes the clinical features of bronchiolitis in order to assist clinicians
in differentiating between bronchiolitis and other causes of dyspnea
in this population. This is especially useful for ED clinicians who do
not routinely treat infants and provides a basis for recommendations
to optimize the clinical evaluation and limit diagnostic testing. The guideline also evaluates treatments frequently used in infants with bronchiolitis
and finds little evidence to support their use in most cases.
The clinical course of bronchiolitis is described as “variable and dynamic, ranging from transient events such as apnea or mucus plugging to progressive respiratory distress from lower airway obstruction.” Increased risk of severe disease is associated with premature
birth (< 37 weeks gestation) and young age of the child (< 12 weeks).
A recent review undertaken to determine the incidence of apnea in
infants hospitalized with RSV bronchiolitis found a significantly higher
risk of apnea in premature infants (reported in 5 of 7 relevant studies)
and a substantially higher incidence of apnea in infants < 3 months of
age (reported in 4 of 4 relevant studies).3
Which associated symptoms should be assessed in infants with
bronchiolitis?
• Recommendation 6a (strong recommendation, evidence
level X): For infants with bronchiolitis, hydration and ability to
take fluids orally should be assessed by clinicians.
Indications for oxygen saturation monitoring and oxygen
administration
• Recommendation 7a (option, evidence level D): If oxyhemoglobin saturation (SpO2) falls persistently below 90% in infants
who were previously healthy, supplemental oxygen is indicated.
Adequate supplemental oxygen should be used to maintain
SpO2 ≥ 90%. If SpO2 is ≥ 90%, the infant is feeding well, and
has minimal respiratory distress, supplemental oxygen may be
discontinued.
Diagnostic maneuvers not routinely recommended for infants with
bronchiolitis include chest radiography, complete blood counts, urinalysis, and virologic testing.
Chest Radiography. According to data reviewed in the guideline,
chest radiographic findings have not been shown to correlate with
severity of disease and are associated with antibiotic administration
but no difference in time to recovery. A review of diagnostic testing
in bronchiolitis found 17 studies presenting chest x-ray data in which
abnormalities on chest x-ray ranged from 20% to 96% and concluded that insufficient data exist to show that chest x-rays reliably
distinguish between viral and bacterial disease or predict severity of
disease.4 A subsequent published study found that radiography in
children aged 2 to 23 months with typical bronchiolitis was almost
always consistent with bronchiolitis (except in 2 of 265 cases, neither
of which indicated a change in acute management), and found that
■
EM Practice Guidelines Update © 2010
3
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Current Guidelines For Diagnosis And Management of Bronchiolitis In The ED
subsequent study supports this claim, finding that in febrile children
admitted with bronchiolitis, the probability of concurrent SBI in patients with a white blood cell count (WBC) count < 5000 and 15,00030,000 was very low and no different than patients with a normal
WBC count.11
clinicians were more likely to treat with antibiotics after reviewing
radiographs even though the radiographic findings did not support
treatment.5 Another recent study found poor inter-observer agreement for x-ray interpretation in children with lower respiratory tract
infections, also leading to potential overuse of antibiotics.6 Despite
its demonstrated lack of utility in bronchiolitis, chest radiography is
prudent in the emergency setting to address the differential diagnosis
in patients with severe dyspnea or atypical presentations.
Virologic Testing. The guideline states that virologic testing, specifically for RSV, has been shown to rarely alter management decisions
or outcomes for the majority of children with clinically diagnosed
bronchiolitis. A review of diagnostic testing in bronchiolitis found numerous studies demonstrating that RSV tests have acceptable sensitivity and specificity, but no data showing that RSV testing affects
clinical outcomes in typical cases of the disease.4
Testing For Serious Bacterial Infections. The AAP practice guideline states that the occurrence of serious bacterial infections (SBI)
such as bacteremia, urinary tract infection (UTI), and meningitis is
very low in infants with bronchiolitis, but does not make a specific
recommendation regarding testing for such infections. The data cited
in the guideline include a prospective study in which the incidence
of UTI in RSV-positive infants ≤ 60 days of age was 5.4% compared
with 10.1% in RSV-negative infants (risk difference: 4.7%, 95% CI:
1.4%-8.1%). In contrast, the rate of bacteremia in this study was very
low in both RSV-positive and RSV-negative infants (1.1% vs 2.3%,
risk difference 1.2%; 95% CI: -0.4%-2.7%), and 0 of the 251 RSVpositive infants with cerebrospinal fluid cultured had bacterial meningitis.7 In a study of infants ≤ 90 days of age presenting to an ED with
RSV-positive bronchiolitis, 5 of 69 (7.2%) tested infants had UTI, 1
of 85 (1.2%) tested infants had true bacteremia, and 0 tested infants
had meningitis.8 A more recent study of hospitalized infants ≤ 90 days
of age found a 2.2% (3 of 136) incidence of UTI in infants with clinical bronchiolitis (and no cases of bacteremia or meningitis in these
infants) compared with a 9.3% (29 of 312) incidence of UTI/urosepsis in infants without clinical bronchiolitis.9 An office-based study of
febrile infants found testing for SBI to be less frequent in infants with
clinical bronchiolitis, and no known SBIs identified among 218 infants
with clinical bronchiolitis.10 Given this conflicting data, many clinicians
do perform urinary testing in young infants with fever and bronchiolitis
in the ED setting.
Bronchodilators. The guideline states that there has been little
demonstrated benefit from various frequently used management
modalities, although it stipulates that a trial of a bronchodilator may
be warranted because some infants show clinical response to either
albuterol or epinephrine. A Cochrane review of bronchodilators other
than epinephrine for bronchiolitis found that bronchodilators produce
small, short-term improvements but do not affect rate of hospitalization or duration of admission.12 A Cochrane review of inhaled epinephrine found no reduction in admission rates among children in the
treatment group, although some studies found a short-term improvement in respiratory rate, oxygen saturation, and clinical score in the
outpatient setting.13
Oral Steroids. The guideline reviews a meta-analysis that showed
no consistent evidence to support the use of oral steroids in infants
with bronchiolitis and 2 studies that showed no benefit with inhaled
steroids. A subsequent Cochrane review found no benefit in length of
stay or clinical score in infants with bronchiolitis treated with systemic
glucocorticoids as compared to placebo, as well as no reduction in
admission or revisit rates.14
Antiviral Therapies. While the data about the utility of antiviral
agents are suboptimal, the guideline recommends reserving antiviral
therapy for children with severe disease or who are at risk for severe
Complete Blood Counts. The guideline states that use of complete
blood counts (CBCs) has not been shown to be useful in diagnosing
or managing bronchiolitis, but cites minimal supporting evidence. A
EM Practice Guidelines Update © 2010
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Current Guidelines For Diagnosis And Management of Bronchiolitis In The ED
disease. Antibiotics are recommended only for infants with concurrent bacterial infection (such as UTI or acute otitis media) and not
for those with radiographic atelectasis or infiltrates, which are often
misinterpreted as possible pneumonia.
Other Treatment Modalities. Treatment modalities that are not
discussed in the guideline include nebulized hypertonic saline, noninvasive ventilation, and heliox (a low-density gas mixture of 70%
helium and 30% oxygen). A recent Cochrane review found evidence
to suggest improvement in clinical severity in infants with bronchiolitis
treated with nebulized 3% saline.15 Nasal continuous positive airway
pressure ventilation is increasingly used in the pediatric intensive care
unit (PICU) setting with resultant decreases in rates of intubation and
should be considered for ED use in infants in severe respiratory distress.16-18 Heliox is also being used in the PICU setting to treat infants
with bronchiolitis and may be appropriate for ED use.19-21
Hydration And Oxygen. The 2 treatments endorsed by the guideline are intravenous (IV) hydration and oxygen administration. The
guideline recommends carefully assessing hydration status of these
infants, and administering IV fluids if feeding is compromised by
tachypnea and/or increased work of breathing. The guideline recommends administering oxygen if SpO2 is < 90% despite suctioning the
nose and oral airway.
EM Practice Guidelines Update © 2010
■
5
ebmedicine.net • April 2010
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Current Guidelines For Diagnosis And Management of Bronchiolitis In The ED
Bronchiolitis In Children. A National Clinical Guideline22
Scottish Intercollegiate Guidelines Network. #91. November 2006.
Link: http://www.sign.ac.uk/guidelines/fulltext/91/index.html
T
his document was developed by a multidisciplinary group of
practicing clinicians using the standard SIGN (Scottish Intercollegiate Guidelines Network) methodology. A systematic literature review was carried out using an explicit search strategy devised
by the SIGN information officer in collaboration with members of the
guideline development group. The guideline was also reviewed in
draft form by independent expert referees. As a final quality control
check, the guideline was reviewed by an editorial group comprising
the relevant specialty representatives on SIGN council.
The target provider population is defined as health professionals in
primary and secondary care involved in the management of infants
with bronchiolitis, parents and carers, and healthcare managers and
policymakers. The guideline applies to infants < 12 months of age
with clinical bronchiolitis as well as premature infants (≤ 37 weeks
gestational age) and infants with congenital heart disease or underlying respiratory disease up to 24 months of age. Bronchiolitis
is defined according to a UK consensus guideline as “a seasonal
viral illness characterized by fever, nasal discharge and dry, wheezy
cough. On examination there are fine inspiratory crackles and/or
high-pitched expiratory wheeze.”
Evidence was evaluated for quality according to predefined, specified criteria and assigned to 1 of 8 levels (1++, 1+, 1-, 2++, 2+, 2-,
3, and 4). Recommendations were graded based on the strength of
evidence for each question.
•
•
•
•
•
The following recommendations are excerpted from the full guideline. Only recommendations pertinent to emergency medicine are
excerpted here.
Grade A: At least 1 meta-analysis, systemic review of RCTs, or
RCT rated as 1++ and directly applicable to the target population;
or a body of evidence consisting principally of studies rated as
1+, directly applicable to the target population, and demonstrating
overall consistency of results.
Grade B: A body of evidence including studies rated as 2++,
directly applicable to the target population, and demonstrating
overall consistency of results; or extrapolated evidence from studies rated as 1++ or 1+.
Grade C: A body of evidence including studies rated as 2+,
directly applicable to the target population and demonstrating
overall consistency of results; or extrapolated evidence from studies rated as 2++.
Grade D: Evidence level 3 or 4; or extrapolated evidence from
studies rated as 2+.
Good practice points: Recommended best practice based on
the clinical experience of the guideline development group.
EM Practice Guidelines Update © 2010
Diagnosis
• Recommendation Grade D: The absence of fever should not
preclude the diagnosis of acute bronchiolitis.
• Recommendation Grade D: In the presence of high fever
(axillary temperature ≥ 39°C [102.2°F]) careful evaluation for
other causes should be undertaken before making a diagnosis
of bronchiolitis.
• Recommendation Grade D: Increased respiratory rate should
arouse suspicion of lower respiratory tract infection, particularly
bronchiolitis or pneumonia.
• Recommendation Grade D: A diagnosis of acute bronchiolitis should be considered in an infant with nasal discharge and
a wheezy cough, in the presence of fine inspiratory crackles
and/or high-pitched expiratory wheeze. Apnea may be a presenting feature.
6
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•
•
Current Guidelines For Diagnosis And Management of Bronchiolitis In The ED
•
Recommendation Grade D: Healthcare professionals should
take seasonality into account when considering the possible diagnosis of acute bronchiolitis.
Good practice point: It is unusual for infants with bronchiolitis to
appear “toxic.” A “toxic” infant who is drowsy, lethargic or irritable,
pale, mottled, and tachycardic requires immediate treatment.
Careful evaluation for other causes should be undertaken before
making a diagnosis of bronchiolitis.
•
•
Risk Factors For Severe Disease
• Recommendation Grade C: Healthcare professionals should be
aware of the increased need for hospital admission in infants born
at less than 35 weeks gestation and in infants who have congenital heart disease or chronic lung disease of prematurity.
• Recommendation Grade C: Healthcare professionals should
inform families that parental smoking is associated with increased
risk of RSV-related hospitalization.
•
Treatment
• Recommendation Grade B: Nebulized ribavirin is not recommended for treatment of acute bronchiolitis in infants.
• Good practice point: Antibiotic therapy is not recommended in
the treatment of acute bronchiolitis in infants.
• Recommendation Grade B: Inhaled beta-2 agonist bronchodilators are not recommended for the treatment of acute bronchiolitis
in infants.
• Good practice point: Nebulized ipratropium is not recommended
for the treatment of acute bronchiolitis in infants.
• Recommendation Grade A: Nebulized epinephrine is not recommended for the treatment of acute bronchiolitis in infants.
• Recommendation Grade A: Inhaled corticosteroids are not recommended for the treatment of acute bronchiolitis in infants.
• Recommendation Grade A: Oral systemic corticosteroids are
not recommended for the treatment of acute bronchiolitis in infants.
• Recommendation Grade A: Chest physiotherapy using vibration
and percussion is not recommended in infants hospitalized with
acute bronchiolitis who are not admitted to intensive care.
• Recommendation Grade D: Nasal suction should be used to
clear secretions in infants hospitalized with acute bronchiolitis
who exhibit respiratory distress due to nasal blockage.
Investigations
• Recommendation Grade C: Pulse oximetry should be performed in every child who presents with acute bronchiolitis.
• Good practice point: Infants with oxygen saturation ≤ 92% require inpatient care.
• Good practice point: Decisionmaking around hospitalization of
infants with oxygen saturations between 92% and 94% should be
supported by a detailed clinical assessment, consideration of the
phase of the illness, and take into account social and geographical factors.
• Good practice point: Blood gas analysis (capillary or arterial)
is usually not indicated in acute bronchiolitis. It may have a role
in the assessment of infants with severe respiratory distress or
who are tiring and may be entering respiratory failure. Knowledge
of arterialized carbon dioxide values may guide referral to high
dependency or intensive care.
• Recommendation Grade C: Chest x-ray should not be performed in infants with typical acute bronchiolitis.
• Good practice point: Chest x-ray should be considered in those
infants where there is diagnostic uncertainty or an atypical disease course.
EM Practice Guidelines Update © 2010
Recommendation Grade D: Unless adequate isolation facilities
are available, rapid testing for RSV is recommended in infants
who require admission to the hospital with acute bronchiolitis, in
order to guide cohort arrangements.
Recommendation Grade C: Routine bacteriological testing (of
blood and urine) is not indicated in infants with typical acute bronchiolitis. Bacteriological testing of urine should be considered in
febrile infants less than 60 days old.
Recommendation Grade D: Full blood count is not indicated in
assessment and management of infants with typical acute bronchiolitis.
Recommendation Grade D: Measurement of urea and electrolytes is not indicated in the routine assessment and management
of infants with typical acute bronchiolitis but should be considered
in those with severe disease.
7
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Current Guidelines For Diagnosis And Management of Bronchiolitis In The ED
•
Recommendation Grade D: Nasogastric feeding should be
considered in infants with acute bronchiolitis who cannot maintain
oral intake or hydration.
• Recommendation Grade D: Infants with oxygen saturation
levels ≤ 92% or who have severe respiratory distress or cyanosis should receive supplemental oxygen by nasal cannula or
facemask.
Editorial Comment
This guideline, developed as a national clinical guideline for Scottish healthcare providers, provides both graded recommendations
and “good practice points.” It should be noted that the “good practice
points” are not evidence-based, but are included in this summary because they address important issues in diagnosis and management of
this disease.
■
Recommendations are similar to those in the AAP practice guideline,
with a few notable exceptions. It is recommended here to administer
supplemental oxygen to infants with SpO2 levels ≤ 92% and to hospitalize these infants. The choice of this SpO2 cutoff is based on 3 studies that found lower oxygen saturation levels on hospital admission to
predict more severe disease and longer lengths of stay. It is also stated
that infants with SpO2 between 92% and 94% may or may not require
hospitalization, depending on the clinical picture, including the phase
of the illness and “social and geographical factors.”
Used with permission, Scottish Intercollegiate Guidelines Network.
This guideline also recommends consideration of nasogastric feeding
in infants who are unable to maintain oral intake or hydration, while the
AAP guideline recommends IV hydration in these infants. This represents a general practice difference between the UK and the US.
■
EM Practice Guidelines Update © 2010
8
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Current Guidelines For Diagnosis And Management of Bronchiolitis In The ED
Evidence-Based Clinical Practice Guideline For Infants With
Bronchiolitis23
Bronchiolitis Guideline Team. Cincinnati Children's Hospital Medical Center. May 2006.
Link: http://www.cincinnatichildrens.org/svc/alpha/h/health-policy/bronchiolitis.htm
T
Assessment And Diagnosis
• Recommendation 3. It is recommended that the clinical history and
physical examination be the basis for a diagnosis of bronchiolitis.
• Recommendation 4. It is recommended that routine diagnostic
studies (RSV swab, chest x-rays, cultures, capillary or arterial
blood gases, rapid influenza, or other rapid viral studies) not be
performed to determine viral infection status or to rule out serious
bacterial infections. Such studies are not generally helpful and
may result in increased rates of unnecessary admission, further
testing, and unnecessary therapies.
his document was developed by a bronchiolitis team consisting of Cincinnati Children's Hospital Medical Center (CCHMC)
physicians, respiratory therapists, members of the Division of
Health Policy Clinical Effectiveness, a community physician, a nursing/patient services provider, and ad hoc advisors. This interdisciplinary working group performed systematic and critical literature reviews
using a grading scale for quality, assigning each citation to 1 of 12
categories, as well as examining current local practices. The recommendations were not graded.
The group identified 6 objectives: 1) Decrease the use of unnecessary diagnostic studies; 2) Decrease the use of medications and
respiratory therapy without observed improvement; 3) Improve the
rate of appropriate admission; 4) Decrease the rate of nosocomial
infection; 5) Improve the use of appropriate monitoring activities; and
6) Decrease length of stay.
Management
• Recommendation 5. It is recommended to consider starting
supplemental oxygen when the saturation is consistently less
than 91% and consider weaning oxygen when consistently
higher than 94%.
• Recommendation 6. It is recommended that scheduled or serial
albuterol aerosol therapies not be routinely used.
• Recommendation 7. It is recommended that a single administration trial inhalation using epinephrine or albuterol may be considered as an option, particularly when there is a family history for
allergy, asthma, or atopy.
• Recommendation 8. It is recommended that inhalation therapy
not be repeated nor continued if there is no improvement in clinical appearance between 15 to 30 minutes after a trial inhalation
therapy.
• Recommendation 9. It is recommended that antibiotics not be
used in the absence of an identified bacterial focus.
Target users include attending physicians, community physicians and
practitioners, ED clinicians, patient/family, and patient care staff. The
guideline is intended primarily for use in children aged less than 12
months and presenting for the first time with bronchiolitis typical in
presentation and clinical course.
The following recommendations are excerpted from the full guideline.
Only recommendations pertinent to emergency medicine are excerpted here. According to CCHMC, this guideline will be updated in 2010
and will be available on their website at the link given above.
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•
•
Current Guidelines For Diagnosis And Management of Bronchiolitis In The ED
Recommendation 10. It is recommended that antihistamines,
oral decongestants, and nasal vasoconstrictors not be used for
routine therapy.
Recommendation 11. It is recommended that steroid therapy not
be given (as inhalations, intravenously, orally, or intramuscularly).
Editorial Comment
This guideline, along with an algorithm to guide clinical care, was
developed for use at CCHMC and made publicly available on the
CCHMC website. Recommendations are similar to those in the AAP
guideline. Of note, recommendations are not graded for the quality of
evidence upon which they are based.
Respiratory Care Therapy
• Recommendation 12. It is recommended that the infant be suctioned, when clinically indicated, before feedings, PRN, and prior
to each inhalation therapy.
• Recommendation 13. It is recommended that other routine
respiratory care therapies not be used, as they have not been
found to be helpful. These include chest physiotherapy, cool mist
therapy, and aerosol therapy with saline.
• Recommendation 14. It is recommended that repeated clinical
assessment be conducted, as this is the most important aspect of
monitoring for deteriorating respiratory status.
• Recommendation 16. It is recommended that scheduled spot
checks of pulse oximetry be utilized in infants with bronchiolitis.
This guideline presents yet another SpO2 cutoff for administering supplemental oxygen (Recommendation 5): “consider starting
supplemental oxygen when the saturation is consistently less than
91% and consider weaning oxygen when consistently higher than
94%.” This recommendation is derived from 1997 National Institutes of Health guidelines, which is an expert panel report.
■
■
Used with permission, Cincinnati Children's Hospital Medical Center.
EM Practice Guidelines Update © 2010
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Current Guidelines For Diagnosis And Management of Bronchiolitis In The ED
References
1.
2.
Subcommittee on Diagnosis and Management of Bronchiolitis. Clinical Practice Guideline: Diagnosis and management of bronchiolitis. Pediatrics.
2006;118(4):1174-1793. (Clinical practice guideline)
3.
Ralston S, Hill V. Incidence of apnea in infants hospitalized with respiratory
syncytial virus bronchiolitis: a systematic review. J Pediatr. 2009;155(5):728-733.
(Systematic review)
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Bordley WC, Viswanathan M, King VJ, et al. Diagnosis and testing in bronchiolitis:
a systematic review. Arch Ped Adolesc Med. 2004;158(2):119-126. (Systematic
review)
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Schuh S, Lalani A, Allen U, et al. Evaluation of the utility of radiography in acute
bronchiolitis. J Pediatr. 2007;150(4):429-433. (Prospective; 265 patients)
6.
Bada C, Carreazo NY, Chalco JP, Huicho L. Inter-observer agreement in interpreting chest x-rays on children with acute lower respiratory tract infections and
concurrent wheezing. Sao Paulo Med J. 2007;125(3):150-154. (Prospective; 200
patients)
7.
Levine DA, Platt SL, Dayan PS, et al. Risk of serious bacterial infection in
young febrile infants with respiratory syncytial virus infections. Pediatrics.
2004;113(6):1728-1734. (Prospective; 1248 patients)
8.
Oray-Schrom P, Phoenix C, St Martin D, Amoateng-Adjepong Y. Sepsis workup
in febrile infants 0-90 days of age with respiratory syncytial virus infection. Pediatr
Emerg Care. 2003;19(5):314-319. (Retrospective; 191 patients)
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13. Hartling L, Wiebe N, Russell K, et al. Epinephrine for bronchiolitis. Cochrane Database Syst Rev. 2004;1:CD003123. (Systematic review)
Mansbach JM, Emond JA, Camargo CA. Bronchiolitis in US emergency departments 1992 to 2000: epidemiology and practice variation. Pediatr Emerg Care.
2005;21(4):242-247. (Retrospective descriptive study)
14. Patel H, Platt R, Lozano JM. WITHDRAWN: Glucocorticoids for acute viral bronchiolitis in infants and young children Cochrane Database Syst Rev.
2008;1:CD004878. (Systematic review)
15. Zhang L, Mendoza-Sassi RA, Wainright C, Klassen TP. Nebulized hypertonic
saline solution for acute bronchiolitis in infants. Cochrane Database Syst Rev.
2008;4:CD006458. (Systematic review)
16. Cambonie G, Milesi C, Jaber S, et al. Nasal continuous positive airway pressure
decreases respiratory muscles overload in young infants with severe acute viral
bronchiolitis. Intensive Care Med. 2008;34:1865-1872. (Prospective; 12 patients)
17. Javouhey E, Barats A, Richard N, Stamm D, Floret D. Non-invasive ventilation
as primary ventilatory support for infants with severe bronchiolitis. Intensive Care
Med. 2008;34(9):1608-1614. (Retrospective; 80 patients)
18. Mayordomo-Colunga J, Medina A, Rey C, et al. Success and failure predictors of
non-invasive ventilation in acute bronchiolitis. An Pediatr. 2009;70(1):34-39. (Prospective; 47 patients)
19. Cambonie G, Milesi C, Fournier-Favre S, et al. Clinical effects of heliox administration for acute bronchiolitis in young infants. Chest. 2006;129(3):676-682. (Prospective; 12 patients)
20. Martinon-Torres F, Rodriguez-Nunez A, Martinon-Sanchez JM. Nasal continuous
positive airway pressure with heliox in infants with acute bronchiolitis. Respir Med.
2006;100(8):1458-1462. (Prospective; 15 patients)
21. Martinon-Torres F, Rodriguez-Nunez A, Martinon-Sanchez JM. Nasal continuous
positive airway pressure with heliox versus air oxygen in infants with acute bronchiolitis: a crossover study. Pediatrics. 2008;121(5):e1190-1195. (Prospective; 12
patients)
Bilavsky E, Shouval DS, Yarden-Bilavsky H, et al. A prospective study of the risk for
serious bacterial infections in hospitalized febrile infants with or without bronchiolitis. Pediatr Infect Dis J. 2008;27(3):269-270. (Prospective; 448 patients)
22. Scottish Intercollegiate Guidelines Network. 91. Bronchiolitis in children. A national
clinical guideline. November 2006. http://www.sign.ac.uk/guidelines/fulltext/91/index.html. Accessed February 1, 2010. (Clinical guideline)
10. Luginbuhl LM, Newman TB, Pantell RH, Finch MA, Wasserman RC. Office-based
treatment and outcomes for febrile infants with clinically diagnosed bronchiolitis.
Pediatrics. 2008;122(5):947-954. (Prospective; 3066 patients)
23. Bronchiolitis Guideline Team, Cincinnati Children's Hospital Medical Center:
Evidence-based clinical practice guideline for medical management of bronchiolitis
in infants 1 year of age or less presenting with a first time episode, http://www.cincinnatichildrens.org/svc/alpha/h/health-policy/ev-based/bronchiolitis.htm. Guideline
1, pages 1-13, August 15, 2005. (Clinical guideline)
11. Purcell K, Fergie J. Lack of usefulness of an abnormal white blood cell count for
predicting a concurrent serious bacterial infection in infants and young children
hospitalized with respiratory syncytial virus lower respiratory tract infection. Pediatr
Infect Disease J. 2007;26(4):311-315. (Retrospective; 672 patients)
12. Gadomski AM, Bhasale AL. Bronchodilators for bronchiolitis. Cochrane Database
Syst Rev. 2006;3:CD001266. (Systematic review)
EM Practice Guidelines Update © 2010
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Update ©© 2009
2010
EM
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ebmedicine.net
• April 2009
2010
ebmedicine.net
• November